Original Article

Incidence, Etiology, and Patterns of Maxillofacial Fractures in Ain-Shams University, Cairo, Egypt: A 4-Year Retrospective Study Amr Mabrouk, MD1

Hesham Helal, MD1

Abdel Rahman Mohamed, MD1

1 Department of Plastic Surgery, Ain Shams University, Cairo, Egypt

Craniomaxillofac Trauma Reconstruction 2014;7:224–232

Abstract

Keywords

► maxillofacial trauma ► maxillofacial fractures incidence ► mandibular fractures ► facial fractures patterns ► maxillofacial fractures

Nada Mahmoud, MD1

Address for correspondence Amr Mabrouk, MD, Department of Plastic Surgery, Ain Shams University, 6 Mahmoud Sadek Street, Cairo 11341, Egypt (e-mail: [email protected]).

Although there is a worldwide increase in maxillofacial trauma incidence; the pattern and etiology of these injuries varies from one country to another depending on socioeconomic, cultural, and environmental factors. This study aims to realize the epidemiological characteristics of maxillofacial fractures in our department. A retrospective cross-sectional study of all facial trauma patients admitted to our department during 2009 to 2012. Patients’ data including gender, age, etiology of trauma, the pattern and demographic distribution of fractures of maxillofacial skeleton, and associated injuries were analyzed and compared with previously published data. The chi-square test was used with a p value of less than 0.05, which was considered statistically significant. There is a significant increase in maxillofacial fractures incidence in the past 2 years than former ones. There is a male predominance with highest incidence in the age group of 20 to 40 years. Road traffic accident is the most common etiological factor followed by violence. There is increase in mandibular fracture incidence compared with midface. The significant increased incidence of maxillofacial fracture due to motor car accidents and assaults in the past 2 years reflects a behavioral change within the community.

Facial fractures are the result of various types of trauma to the face, and may occur in isolation or combined with other injuries.1 The epidemiological assessment of maxillofacial fractures represents a special interest to identify the potential trend of their frequency, age, gender, and anatomic distribution especially when comparison of these patterns is done over time periods. The incidence of maxillofacial fractures varies widely between different countries depending on local demographic and socioeconomic status.2,3 Generally, the incidence is higher in males than in females with peak incidence between 20 and 30 years.4 Many causes had been incriminated in the etiology of facial fractures; however, the main causes worldwide are traffic accidents, assaults, falls, and sport injuries.5,6 Motor car accidents (MCA) have always been the most

frequent cause of facial fractures worldwide; however, recent studies have shown that assaults are now the most common cause in many developed countries. Our hospital is serving more than 4 million people living in the eastern region of Cairo besides draining areas of the country side near this region. The presence of our plastic surgery department with surgeons specializing in maxillofacial surgery and the lack of public hospitals specializing in this field in the surrounding region has led it to act as a tertiary care center and have increased the number of injuries likely to be referred and treated in this hospital, thus offers a model that could be a sign of our community. In this article, we intend to assess the epidemiological features of maxillofacial fractures treated at our department for the period from January 2009 to December 2012.

received August 5, 2013 accepted after revision August 7, 2013 published online May 21, 2014

Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.

DOI http://dx.doi.org/ 10.1055/s-0034-1374061. ISSN 1943-3875.

Downloaded by: Collections and Technical Services Department. Copyrighted material.

224

Incidence, Etiology, and Patterns of Maxillofacial Fractures, Egypt

Mabrouk et al.

225

Figure 2 Mean age distribution of patients.

region affected. A p value of less than 0.05 was considered statistically significant.

Patients and Methods A total of 330 patients suffering from facial trauma and suspected facial bone fractures including the nose, frontal bone, maxilla, zygoma, and mandible were presented to the emergency room in our hospital in the period between 2009 and 2012. Of these, only 215 patients were confirmed to have facial fractures necessitating surgical intervention by computed tomography (axial and coronal slices þ three-dimensional reconstructed images) and so admitted to our department and operated upon. We retrospectively analyzed their medical records and data were collected concerning sex, age, cause of injury, type of fracture, treatment modality, and postoperative complications. Patients were divided into seven age groups: 0 to 10year-old, 11 to 20-year-old, 21 to 30-year-old, 31 to 40-yearold, 41 to 50-year-old, 51 to 60-year-old, and > 60-year-old groups. The following analyses were conducted for each age group: causes of injury (e.g., motor vehicle accidents, falling, violence, and gunshot) and fracture type (e.g., nasal bone, zygoma, maxilla, mandible, and frontal bone fractures) and clinical outcomes.

Statistical Analysis Patient characteristics were analyzed using descriptive statistics; qualitative variables (absolute and relative frequencies) and quantitative variables (means and standard deviation [SD]). The chi-square test was used to evaluate the association between gender, cause of facial fractures, and

Results Patients’ Data A total of 215 patients were evaluated for the study in which 183 were males and 32 were females. There was a vast male predominance in all age groups with an overall male-tofemale ratio of 5.7:1. The age group 21 to 30 years accounted largest in both sexes (in males and in females) followed by patients in the age group 31 to 40 years (►Fig. 1). The annual distribution of patients based on the number and gender of patients is shown in ►Table 1. There was no statistical difference among the individual years. The age of the patients ranged from 2 to 62 years with a mean age 25.7256 years (SD, 9.16842 years). The highest mean was in 2009 (28.8462) whereas the least was in 2010 (22.9592) with no statistical difference between the 4 years of study (►Fig. 2). Among these, the third and fourth decade age groups were significantly more likely to sustain facial fractures (75.3%) with a peak incidence of maxillofacial trauma observed at 25 years (p < 0.05). A decreasing trend was seen with age proceeding to both the extremes (►Fig. 3).

Trauma Type The most common cause of injury throughout the study was violence and MCA, followed by gunshot and fall from height. The mean age of the patients involved in violence was 27.6364 years (SD, 6.94176 years), whereas the mean age

Table 1 Annual distribution of fractures based on gender difference Year Sex

Male Female

Total

Total

2009

2010

2011

2012

Count

43

41

52

47

183

% within year

82.7

83.7

86.7

87.0

85.1

Count

9

8

8

7

32

% within year

17.3

16.3

13.3

13.0

14.9

Count

52

49

60

54

215

% within year

100.0

100.0

100.0

100.0

100.0

Craniomaxillofacial Trauma and Reconstruction

Vol. 7

No. 3/2014

Downloaded by: Collections and Technical Services Department. Copyrighted material.

Figure 1 Age and gender distribution of patients.

Incidence, Etiology, and Patterns of Maxillofacial Fractures, Egypt

Mabrouk et al.

Figure 3 Fracture site distribution based on age group.

of those who were not involved in violence was 20.5866 years (►Table 2). The annual distribution of patients based on cause of injury showed that MCA was statistically significantly higher in 2009 and 2010 (p < 0.05); however, a shift occurred in 2011 and 2012 leading to statistically significant increase in the rate of violence than the other causes of injury in the previous 2 years (p < 0.05) as shown in ►Fig. 4. Almost all patients involved in gunshot injuries and approximately 85% of the patients involved in violence and MCA were males (►Fig. 5). In all the age groups, violence and MCA constituted the main causes of fractures with a significant higher difference than other causes (p < 0.05). In patients younger than 10 years, the fractures were mostly due to fall from height. Falling was a common cause of injury in children younger than 15 years. Violence was more common in those older than 27 years whereas firearms were common in those older than 26 years (►Table 3).

Pattern and Site of Fracture There were 179 (83.2%) simple facial fractures and 36 (16.7%) multiple facial fractures. Significantly, mandibular fractures were the most common among all facial bone fractures, accounting for 51.6% of all fractures (p < 0.05), zygomaticomaxillary fractures (25.6%) and nasal fractures (16.7%) were the next most common (►Fig. 6). In all age groups, fractures of the mandible and zygoma constituted the foremost locations of fractures with a signifi-

cant higher difference than other locations (p < 0.05) (►Table 4). The site of fracture distribution based on gender differences showed that fractures were mainly affecting the mandible and zygoma with higher percentage of mandible and nasal bone affection within the male sex group than within the female sex group but with no significant statistical difference (►Table 5). Fracture mandible showed significantly statistical higher incidence than other sites based on the cause of injury (p < 0.05) except for the MCA where fracture zygoma was higher but with no statistical difference (►Fig. 7). The annual distribution of patients based on the site of fracture is shown in ►Table 6.There was no statistical difference among the individual years.

Treatment Modalities Surgical treatment was performed on the majority of the patients throughout the 4 years. A total of 215 operations were done with open reduction and internal fixation showed the higher frequency (90.7%) with no significant statistical difference among the individual years. The annual distribution of procedures done for the patients is shown in ►Table 7. There was no statistical difference among the individual years. The procedure distribution of patients based on age is shown in ►Table 8. There was no statistical difference among the different age groups. Over 90% of patients involved in gunshot injuries, violence, and MCA necessitated open reduction and internal fixation,

Table 2 Cause of fracture distribution of patients Number

Percent

Mean age

Std. deviation

Fall from height

17

7.9

15.4118

15.28913

Gunshot

22

10.2

25.9091

4.95608

Violence

88

40.9

27.6364

6.94176

Motor car accident

88

40.9

25.7614

9.22888

Total

215

100.0

25.7256

9.16842

Craniomaxillofacial Trauma and Reconstruction

Vol. 7

No. 3/2014

Downloaded by: Collections and Technical Services Department. Copyrighted material.

226

Mabrouk et al.

227

Downloaded by: Collections and Technical Services Department. Copyrighted material.

Incidence, Etiology, and Patterns of Maxillofacial Fractures, Egypt

Figure 4 Cause of fracture distribution based on year.

Figure 5 Cause of fracture distribution based on gender.

Table 3 Cause of fracture distribution based on age group ALL

Fall

Violence

MCA

Firearms

0–10

10

0

2

0

11–20

3

14

16

3

21–30

2

46

47

17

31–40

1

26

19

2

41–50

0

2

2

0

51–60

0

0

2

0

60

1

0

0

0

Total

17

88

88

22

Abbreviation: MCA, motor car accidents. Craniomaxillofacial Trauma and Reconstruction

Vol. 7

No. 3/2014

Incidence, Etiology, and Patterns of Maxillofacial Fractures, Egypt

Mabrouk et al.

Postsurgical Complications The postoperative complications included infection, paresthesia, diplopia, ectropion, and malocclusion (►Table 9).

Discussion

Figure 6 Site of facial fractures distribution in patients.

whereas patients involved in falls were treated almost equally by open reduction and internal fixation and mandibulomaxillary fixation (►Fig. 8). All zygomaticomaxillary complex, frontal bone, and 89.2% of mandibular fractures needed open reduction and internal fixation, whereas all nasal bone fractures were treated only with splinting (►Fig. 9).

Many studies all over the world had been conducted to study the epidemiology and characteristics of maxillofacial trauma in a single medical center7–12; however, there are very few studies regarding the Egyptian population.13 This study was done to review the different epidemiological features of maxillofacial fractures as the incidence, cause, and site of fracture and patients’ data as age, sex, and also surgical procedures and postoperative complications and to correlate these different features with each other within the years of study. In this study, an overall male-to-female ratio was observed as 5.7:1, this is similar to findings from other studies12,14 and higher than other studies.15–17 This male dominance reflects cultural and/or employment differences in our eastern community and express the probability of exposure of male to

Table 4 Site of fracture distribution based on age group ALL

Mandible

Zygoma

Nose

Frontal

Maxilla

0–10

12

0

0

0

0

11–20

13

13

1

7

0

21–30

54

34

3

18

3

31–40

28

8

3

9

2

41–50

2

0

0

2

0

51–60

1

0

1

0

0

60 Total

1

0

0

0

0

111

55

8

36

5

Table 5 Site of fracture distribution based on gender Sex Affected part

Total

Male

Female 9

Zygoma

Count

46

% within sex

25.1

28.1

25.6

Maxilla

Count

4

1

5

% within sex

2.2

3.1

2.3

Mandible

Count

95

16

111

% within sex

51.9

50.0

51.6

Nasal bone

Count

6

2

8

% within sex

3.3

6.3

3.7

Frontal bone Total

Craniomaxillofacial Trauma and Reconstruction

Vol. 7

No. 3/2014

55

Count

32

4

36

% within sex

17.5

12.5

16.7

Count

183

32

215

% within sex

100.0

100.0

100.0

Downloaded by: Collections and Technical Services Department. Copyrighted material.

228

Mabrouk et al.

Figure 7 Site of fracture distribution based on cause of fracture.

Table 6 Site of fracture distribution of fractures based on year Year Affected part

Zygoma

Count

Total

2009

2010

2011

2012

15

15

9

16

55

% within year

28.8

30.6

15.0

29.6

25.6

Count

3

0

2

0

5

% within year

5.8

0

3.3

0

2.3

Count

23

19

40

29

111

% within year

44.2

38.8

66.7

53.7

51.6

Frontal bone

Count

5

2

0

1

8

% within year

9.6

4.1

0

1.9

3.7%

Nasal bone

Count

6

13

9

8

36

% within year

11.5

26.5

15.0

14.8

16.7

Count

52

49

60

54

215

% within year

100.0

100.0

100.0

100.0

100.0

Maxilla Mandible

Total

Table 7 Procedure distribution of fractures based on year Year Procedure

2009

2010

2011

2012

3

5

2

2

MMF

Count % within year

5.8

10.2

3.3

3.7

5.6

ORIF

Count

44

42

58

51

195

% within year

84.6

85.7

96.7

94.4

90.7

Splinting Total

Total 12

Count

5

2

0

1

8

% within year

9.6

4.1

0

1.9

3.7

Count

52

49

60

54

215

% within year

100.0

100.0

100.0

100.0

100.0

Abbreviations: MMF, mandibulomaxillary fixation; ORIF, open reduction internal fixation. Craniomaxillofacial Trauma and Reconstruction

Vol. 7

No. 3/2014

229

Downloaded by: Collections and Technical Services Department. Copyrighted material.

Incidence, Etiology, and Patterns of Maxillofacial Fractures, Egypt

Incidence, Etiology, and Patterns of Maxillofacial Fractures, Egypt

Mabrouk et al.

Table 8 Procedure distribution based on age group ALL

Number

Splinting

MMF

ORIF

0–10

12

0

12

0

11–20

34

1

0

33

21–30

112

3

0

109

31–40

50

3

0

47

41–50

4

0

0

4

51–60

2

1

0

1

60 Total

1

0

0

1

215

8

12

195

Abbreviations: MMF, mandibulomaxillary fixation; ORIF, open reduction internal fixation.

high risk jobs and outdoor daily life risks that could lead to facial injuries. In agreement with many other studies,18–20 the third and fourth decade groups of age in both sexes with mean age of 25.7 years were significantly more likely to sustain facial fractures. That is because it is the energetic period of life where an individual takes part in hazardous sports, fast driving, and more likely to be involved in violence acts. In all age groups, violence and MCA constituted the main causes of fractures in concordance with other studies.21,22 The

Figure 8 Procedure distribution based on cause of fracture.

Figure 9 Procedure distribution based on site of fracture.

Craniomaxillofacial Trauma and Reconstruction

Vol. 7

No. 3/2014

maxillofacial fracture in the patient over 60 years was due to fall and this matches with other studies stating that falls are the main cause of facial injury in elderly patients.23 As most of the studies stated, the etiology of injuries varied considerably between countries as regard to the socioeconomic status.2,3 The main causes of maxillofacial fractures all over the world are road accidents, assaults, fall, and sportsrelated injuries.5,6 In our study, the percentage of maxillofacial fractures due to MCA in 2009 and 2010 were 65.4 and 73.5%, respectively, and constituted the main cause of injury.

Downloaded by: Collections and Technical Services Department. Copyrighted material.

230

Incidence, Etiology, and Patterns of Maxillofacial Fractures, Egypt Table 9 Postoperative complications Complication

Number of patients

Infection

7

Malocclusion

5

Diplopia

3

Ectropion

2

Paresthesia

3

Total

20

Mabrouk et al.

231

the most common complication was infection (35%) treated conservatively with broad spectrum antibiotics and also local wound care. Malocclusion took place in five patients; all of them needed a second surgery. The significant increased incidence of maxillofacial fracture due to MCA and assaults in the past 2 years reflects a behavioral change within the community and showed the necessity for a national plan that should be headed to prevention and treatment.

References 1 Erdmann D, Follmar KE, Debruijn M, et al. A retrospective analysis

of facial fracture etiologies. Ann Plast Surg 2008;60(4):398–403 2 Kruger E, Smith K, Tennant M. Jaw fractures in the indigenous and

3

4

5

6

7

8 9

10

11

12

13

14

15

16

17

18

non-indigenous populations of Western Australia: 1999-2003. Int J Oral Maxillofac Surg 2006;35(7):658–662 van den Bergh B, Karagozoglu KH, Heymans MW, Forouzanfar T. Aetiology and incidence of maxillofacial trauma in Amsterdam: a retrospective analysis of 579 patients. J Craniomaxillofac Surg 2012;40(6):e165–e169 Paes JV, de Sá Paes FL, Valiati R, de Oliveira MG, Pagnoncelli RM. Retrospective study of prevalence of face fractures in southern Brazil. Indian J Dent Res 2012;23(1):80–86 Ellis E III, Moos KF, el-Attar A. Ten years of mandibular fractures: an analysis of 2,137 cases. Oral Surg Oral Med Oral Pathol 1985;59(2): 120–129 Lee JH, Cho BK, Park WJ. A 4-year retrospective study of facial fractures on Jeju, Korea. J Craniomaxillofac Surg 2010;38(3): 192–196 Gassner R, Tuli T, Hächl O, Rudisch A, Ulmer H. Cranio-maxillofacial trauma: a 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg 2003;31(1):51–61 Motamedi MH. An assessment of maxillofacial fractures: a 5-year study of 237 patients. J Oral Maxillofac Surg 2003;61(1):61–64 Ozkaya O, Turgut G, Kayali MU, Uğurlu K, Kuran I, Baş L. A retrospective study on the epidemiology and treatment of maxillofacial fractures. Ulus Travma Acil Cerrahi Derg 2009;15(3): 262–266 Leles JL, dos Santos EJ, Jorge FD, da Silva ET, Leles CR. Risk factors for maxillofacial injuries in a Brazilian emergency hospital sample. J Appl Oral Sci 2010;18(1):23–29 Zix JA, Schaller B, Lieger O, Saulacic N, Thorén H, Iizuka T. Incidence, aetiology and pattern of mandibular fractures in central Switzerland. Swiss Med Wkly 2011;141:w13207 Kapoor P, Kalra N. A retrospective analysis of maxillofacial injuries in patients reporting to a tertiary care hospital in East Delhi. Int J Crit Illn Inj Sci 2012;2(1):6–10 Sakr K, Farag IA, Zeitoun IM. Review of 509 mandibular fractures treated at the University Hospital, Alexandria, Egypt. Br J Oral Maxillofac Surg 2006;44(2):107–111 Pombo M, Luaces-Rey R, Pértega S, et al. Review of 793 facial fractures treated from 2001 to 2008 in a coruña university hospital: types and etiology. Craniomaxillofac Trauma Reconstr 2010;3(1):49–54 Chandra Shekar BR, Reddy C. A five-year retrospective statistical analysis of maxillofacial injuries in patients admitted and treated at two hospitals of Mysore city. Indian J Dent Res 2008;19(4):304–308 Ravindran V, Ravindran Nair KS. Metaanalysis of maxillofacial trauma in the northern districts of Kerala: one year prospective study. J Maxillofac Oral Surg 2011;10(4):321–327 Momeni H, Shahnaseri S, Hamzeheil Z. Distribution assessment of maxillofacial fractures in trauma admitted patients in Yazd hospitals: an epidemiologic study. Dent Res J (Isfahan) 2011;8(Suppl 1):S80–S83 Cheema SA, Amin F. Incidence and causes of maxillofacial skeletal injuries at the Mayo Hospital in Lahore, Pakistan. Br J Oral Maxillofac Surg 2006;44(3):232–234 Craniomaxillofacial Trauma and Reconstruction

Vol. 7

No. 3/2014

Downloaded by: Collections and Technical Services Department. Copyrighted material.

These findings are in agreement with other studies from developing countries.24,25 This increase is not in concordance with regular and frequent stress on the use of seat belts and helmets, in addition to many new well-constructed highways with regular maintenance. We think that this is because of a behavioral deficit of some individuals showing ignorance of traffic rules and regulations. However, this had significantly decreased in comparison to 2011 and 2012 (16.7 and 14.8%, respectively) with a great increase in the frequency of interpersonal violence accounting for more than 55% of the injuries. This is similar to findings from other studies.26,27 Violence was significantly more common in males than in females (5.8:1) as results from other studies,16 and also the rate of incidence was much higher in those older than 27 years than all other age groups which was also similar to other studies.3 The significant increase in the usage of firearms in the past 2 years of the study reflects a change in some cultural habits and necessitates the implication of new preventive measures to control this increase that pose unexpected consequences. In our study, mandibular fractures were the most common among all other sites accounting for 51.6% of all fractures as mentioned in many other studies12,14; however, this is not corresponding with other studies that found that nasal bones and zygomaticomaxillary complex the most common site of injury due to their prominent position within the facial skeleton.10,28 Concerning the site of fracture in relation to cause of injury, mandibular fractures were likely to occur with violence and this agrees with the common thought that assaults are significant predictors for isolated mandible fractures.1 On the contrary, all other sites were more likely in MCA. Because of the high variability in the maxillofacial fracture patterns; many treatment modalities have been proposed depending on the own features of each fracture and also surgeons’ experience and that is why standardization of a surgical technique is not possible and combination of different methods are preferred. In our study, open reduction and internal fixation with titanium plates was the most commonly used method with the usage of bone grafts in old fractures only while mandibulomaxillary fixation alone and splinting were used in less than 10% of cases. The most frequent postoperative complications after treatment of maxillofacial fractures are malocclusion, infection, and nonunion.29 We had a complication rate of 9.3% (n ¼ 20);

Incidence, Etiology, and Patterns of Maxillofacial Fractures, Egypt

Mabrouk et al.

19 Oginni FO, Ajike SO, Obuekwe ON, Fasola O. A prospective multi-

24 Fasola AO, Lawoyin JO, Obiechina AE, Arotiba JT. Inner city maxil-

center study of injury profile, severity and risk factors in 221 motorcycle-injured Nigerian maxillofacial patients. Traffic Inj Prev 2009;10(1):70–75 Al Ahmed HE, Jaber MA, Abu Fanas SH, Karas M. The pattern of maxillofacial fractures in Sharjah, United Arab Emirates: a review of 230 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98(2):166–170 Adebayo ET, Ajike OS, Adekeye EO. Analysis of the pattern of maxillofacial fractures in Kaduna, Nigeria. Br J Oral Maxillofac Surg 2003;41(6):396–400 Bakardjiev A, Pechalova P. Maxillofacial fractures in Southern Bulgaria - a retrospective study of 1706 cases. J Craniomaxillofac Surg 2007;35(3):147–150 Iida S, Kogo M, Sugiura T, Mima T, Matsuya T. Retrospective analysis of 1502 patients with facial fractures. Int J Oral Maxillofac Surg 2001;30(4):286–290

lofacial fractures due to road traffic accidents. Dent Traumatol 2003;19(1):2–5 Ansari MH. Maxillofacial fractures in Hamedan province, Iran: a retrospective study (1987-2001). J Craniomaxillofac Surg 2004; 32(1):28–34 Depprich R, Handschel J, Hornung J, Meyer U, Kübler NR. Causation, therapy and complications of treating mandibular fractures a retrospective analysis of 10 years [in German]. Mund Kiefer Gesichtschir 2007;11(1):19–26 Lee KH. Epidemiology of mandibular fractures in a tertiary trauma centre. Emerg Med J 2008;25(9):565–568 Eggensperger N, Smolka K, Scheidegger B, Zimmermann H, Iizuka T. A 3-year survey of assault-related maxillofacial fractures in central Switzerland. J Craniomaxillofac Surg 2007;35(3):161–167 Güven O. Stabilisation of the delayed zygomatic arch fracture. Int J Oral Maxillofac Surg 1987;16(4):445–447

20

21

22

23

25

26

27 28

29

Downloaded by: Collections and Technical Services Department. Copyrighted material.

232

Craniomaxillofacial Trauma and Reconstruction

Vol. 7

No. 3/2014

Incidence, etiology, and patterns of maxillofacial fractures in ain-shams university, cairo, egypt: a 4-year retrospective study.

Although there is a worldwide increase in maxillofacial trauma incidence; the pattern and etiology of these injuries varies from one country to anothe...
254KB Sizes 0 Downloads 4 Views